Shock

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2558

Topics to cover
Shock

classification
Approach to hypotensive patient
Management of septic shock

Shock= inadequate tissue oxygenation

SBP < 90 mm Hg, MAP < 70 mm Hg,
SBP decrease > 40 mm Hg in adults

Organ
dysfunction

case
63

y/o male known HT, DLP and RA, on MTx,

azathioprine come in with diarrhea , fatigue
x4 day, today fell shortness of breath
BP 76/50, HR 112/min, RR 24, T 36.5
CVS: normal S1 S2, no murmur
Lung : wheezing diffusely , crepitation
Leg: no edema
EKG: old inferior wall MI
CXR: cardiomegaly, perihilar infiltration,+
minor fissure

MAP< 65mmHg

Signs of
poor tissue perfusion
Urine output
Abnormal mentation
consciousness
Metabolic acidosis

SHOCK
BP = CO x SVR

BP = CO x SVR
BP = CO x SVR BP = CO x SVR
Compensates
Compensates
CO
SVR
Clinical = peripheral Clinical = peripheral
vasodilatation +
Vasoconstriction +
High Stroke volume
Low Stroke volume

Low output shock

high output shock

BP = CO x SVR
Low output shock

high output shock

1ry process = low CO

CO= SV x HR

1ry process = low SVR

Slow HR :
pace maker
conduction
High HR:
possible from low SV
Preload
Contractility

Vasodilator shock
Hypovolemic shock
Obstructive shock
Cardiogenic shock

Low output

hypovolemia

High output

hypov AMI
olemic

Rt.heart
syndrome

sepsis

JVP

Capry refill
( 3 sec)
Pulse
pressure

+
+

S3 gallop
crepitation

Shock : classification & Rx

BP = Cardiac output x SVR
Cardiac output= stroke volume x HR
BP = preload x contractility x HR x SVR
Hypovolemic

Rx = Fluid

Cardiogenic

Inotrope// HR

Septic

Vasoactive

Management of Shock

Resuscitation &
Maintain
hemodynamic

Correct the
primary processes

Antibiotic &
drainage

Septic shock
Endotoxin

Endothelial injury

Myocardial
depressant factor

Fluid
therapy
Vascular Endothelin+ NO
leakage
3rd

space loss +
interstitial edema

Vasopressor
therapy

contractility

Early= vasodilator

inotrope

Late=vasoconstrictor

Revised 4/2015 by the SSC Executive Committee

Take home messages

Shock:

inadequate tissue oxygenation leading to

multi-organ dysfunction
Shock can classify in 2 group
High output: sepsis
Low output: hypovolemic, obstructive, cardiogenic
Early detection & management can reduce mortality
Antibiotic in 1st hour
Fluid: crystalloid 30 ml/kg in first 3 hr
Vasopressor of choice is norepinephrine